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16A-020 BUILDING 1, 2, 3 & 4 (2) I FAIRWAY VILLAGE-BLDGS 1,2, 3,4 BP-2016-1114 GIs#: COMMO WEALTH OF MASSACHUSETTS MapBlock: 16A-020 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:vinyl siding BUILDING PERMIT Permit# BP-2016-1114 Project# JS-2016-001900 Est. Cost: $125000.00 Fee: $1000.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS KORYTOSKI 070047 Lot Size(sq. ft.): Owner: HAMPSHIRE PROPERTY MANAGEMENT Zoning. URA(102)/WP(17)/WSP(15)/ .Applicant: THOMAS KORYTOSKI AT. FAIRWAY VILLAGE - BLDGS 1, 2, 14 Applicant Address: Phone: Insurance: 359 BARDWELL ST (413) 323-4393 O BELCH ERTOWNMAO 1007 ISSUED ON:3/18/2016 0:00:00 TO PERFORM THE FOLLOWING WORK«REPLACE SIDINGNVINDOWS UNITS 101-103,104-107,108-111,112-115,205-208,209-213,301-304,305-310,311-315,405-408 POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount; Building 3/18/2016 0:00:00 $1000.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner De artmen i 'Fxxy,�2, t.� .sr r5t� s`-����L�,.} City of Northampton status of�Perpo �,� � ,,.r e�.,Y.'k.F4f�`��&M-RUN ° t wilding Department Curb Ct�C/,Oriueway,P�rrrttt« � •` ' �4s-rr "moi X5-0, W 212 Main Street SewerlSefitic,A airaTilrty � �� �� � "' � _ t t � W Room 100VUa l felL/�ua��abili '11£f1-� OPP vZ t� +,- •4 n rn 4A hampton, MA 01060 TwoSetso€StrtttctFJfa Pla�}sir* � �ti t phone 413-587-1240 Fax 413-587-1272: Pla Sf Pa�"s �" � } ,f1TW ,sir�s'"g `a''. m"ev+1'Vii" ` .•eri APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVAtE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION �1 ti - r Thts secttoirfobe.complefed�by�of}cep, t� *r_", 1.1 Property Address: 7 S ! /�� /y J T y 1—�C LS J _ = (s/ CJ o<- J .•...1411 p �- -�E'ot �� "q�� tJ�ttt - . t, J i it :}z..� _'� spy F�''t �- ''4'� � g` ..a.t •rti - t O t(J t 6q -107 t OF- 0/ 112XI-1 a v-, � I -3 cJ f 3'!-/ s - ' - r•aF DtrctO L! o-;--yaE , _ ° CB DlstriEt +. 1 a SECTION 2.:-PROPERTY OWNERSHIP/AUTHORIZED AGENT: 2.1 Owner of Record: AX 69& Name nt) Current Mallingg Ad ress: AA Q/p16CX/0,-) / syl9d 7 .1~•+r�TC7,v� ��r Telephone signat re 'i/3 2.2 Authorized Agent:_ T d -f . 101p, f ,6o X �o "e-IOX `(4 Name(Print) Current Mailing Address: Sign re Telephone SECTION 3-ESTImATE CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Oj ;('a)Building Permit Fee 2. Electrical '(b)'Estim6ted Total Cost of Construction from 6 " 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) / S!?OD Check Number This Section For Offi'ial Use Oni Date Building Permit-Number: Issued: Signature: Building Commissionedlnsp:'a r of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 71�is column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage (Ut area minus bldg&�aved #of Parking Spaces A. Has aSpecial Permit/Variance/Finding ever been issued for/on the site? /�� �� � NO �~~�� DONT KNOW \_� YES �� IF YES, date issued: IF YES: Was the permit recorded at the Registry ofDeeds? . NO 0 DONT KNOW 0 YES ' IF YES: enter Book Pag and/or DocumenL# ��/�� �� B. Does the site contain a brook, body of water orwetlands? NO UDON7 KNKNOWYES �_� � IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0Obtained (- / Date Issued: C. Do any signs exist on the property? YES 0 NO 0 |FYES, describe size, type and location: D. Are there any proposed chanQestooradd1tionsofsignsintendedf¢rtheprnperty7 YEI n NO 0 IF YES, describe size' type and location: E. Will the construction activity disturb( hng. Qrad{nexcavation,orfi|Ung)over 1acre nris it part ofacommon plan , that will disturb over 1 acre? YES [ ] NO I& IF YES,then a Northampton Storm Water Management Permit from the DPW is required. / '| ' ` ' | Y | � i i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor- j Not Applicable £ Name of License Haider / : / 047,1 j I �5 5 r C :� --°6-17 O G License Number AddressExpiration Date U", 5 r 1<J f jj rig j-.e' t U 3 `l Signature/,), Telephone W 3 9 Regisfered HomeImprovement-Contractor `,: Not Applicable £ .� D dv r`✓�c/c T`r' C z-C (lit O.Tr Company Name 'Registration Number Address Expiration Date t�lL4log u�� 'f� Q rrJl � Telephone(it 3 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.-152,§26C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes. . £ No...... £ �:1 �'. .�ome_t�wuer=.Egemi�tx4 The current exemption for"homeowners"was extended to inclgde Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 730. Sixth Edition Section 103.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in I two-Year period shall not be considered a homeowner. Such"homeowner'shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building'permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature, SECTION 6-DESCRIPTION OF PROPOSED'WORK(c heck all applicable) New House f7 Addition F-1 ReplacemenLwjndows Alteration(s) Roofing Or Doors 25', Accessory Bldg. ❑ Demolition ED New Signs fr-1] Decks SIdingA Other Ir-3j Brief De§,cn'ptio4 of Propos lot- 103 io Ll- to 7 to Y - TTT 11-2 t 1 0 1 ' "y Aff- (3 Work:JK(f ��I&e -5�� 'ZVVIA a-'5 L-51 I'M -A05 A 3 of - 3e>'l 3 es- 3. f 13 1 3 IS- Alteration of existing bedroom_Yes No Adding new bedroom_Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a'If house arrd-o -on 116WIng: New. a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of-heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance, Masscheck Energy Compliance form attached? h. Type of construction 1. Is construction within 100 ft. of wetlands?-Yes No. Is construction within 100 yr. floodplain-Yes-No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes-No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION'-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR-A.PP LIES-F.0.R.BUILDING DING PERMIT LW4 as Owner of the subject property hereby authorize 14iloe4 5 T- to act on rnI b h If It matters rela y e a in to work authorized by this building permit application. :2 (& Signafur of Owner 15dle as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed yder the pains and penalties of perjury. Print Name Signa ure of Owner/Agent Date The Commonwealth of Massachusetts Department of Industrial Accidents 11111R� Office ofInvestigations 600 Washington.street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/IElectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Alf � ('D,t/Ar vey r- %/0-f-, L C Address: 3>�1 ���ccie l 5 7-- City/State/Zip: -City/State/Zip: t3fle°4T&�'-� --O' 0 i 04,,'�7 Phone#: ��� S�© ' Fd X1.4 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees nd have workers' 9 ❑Building addition comp.insurance.$ [No workers comp.insurance required.] 5. >k We are.a 10.7 Electrical repairs or additions co>~poration and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no q employees. No workers' 13. Other , %d�G-e �y r�r1' cs� comp.insurance required.] e 1©Gi cP.� -� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and tbl n hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workors'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un rthe pai and penalties ofperjury that the information provided above is true and correct. Si afore: Date: .�f 7" Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# LL6. Other Authority(circle one): d of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector t Person: Phone#: City o f Northampton Massachusetts f• : 10 DEPARTAXNT OF .BUILDING Tt1TSPECT101W 212 Main Street ® Municipal Building Northampton. MA 42460 '�st+TY—W�{t4 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner"as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be i responsible to make sure that the trades hired secure their proper permits in conjunction to the building ' permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made 1, understand the above, (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date kddress of work location City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit-all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: '7-;au, e l.< The debris will be received by: _L/ lle k /fie c zc Building permit number: Name of Permit Applicant ,11-e -e- �C-Qti:67-a- L C Date Signature of Permit Applicant